Use of advanced technologies across the wound care spectrum: prologue

Abstract

The growing trends of ageing populations and increasing prevalence of diabetes have given rise to an expanding number of problematic acute and chronic wounds. Over the past two decades, the use of negative pressure wound therapy (NPWT) with and without instillation of topical wound solutions has expanded to include treatment of a large variety of wounds. Additionally, the use of NPWT specifically designed for use over closed surgical incisions has been associated with favourable results. The recent introduction of an automated epidermal harvesting system, which neither creates a donor site wound nor requires the use of a surgeon, operating room or anaesthesia, has facilitated the use of epidermal grafting. This supplement highlights some of the advanced wound approaches that have been developed to address challenging wounds and the growing burden of wound care affecting both the patient and the health care system.

Introduction

Problematic wounds include chronic wounds (CWs), which are defined as those wounds that fail to heal in a timely fashion, and large and deep acute wounds (AWs) 1. CWs are prevalent as well as costly and affect both the patient's life and quality of life. CWs include diabetic foot ulcers (DFUs), pressure ulcers (PUs) and venous leg ulcers (VLUs), and it is estimated that over 6 million Americans suffer from CWs 1. While the exact treatment costs of CWs are not known, recent estimates suggest that the annual direct treatment costs for these patients may be well over $40 billion 1. Additionally, there is recent recognition that patients with CWs have reduced life expectancy and have greater mortality than many cancer patients 2.

The exact number of problematic AWs is even more difficult to estimate. Problematic AWs may arise as a result of trauma and/or surgery, and similar to patients with CWs, patients with problematic AWs may also be suffering from multiple comorbidities. Problematic AWs are often painful and malodorous, drain fluid and exudate, and leave the patient with decreased mobility and associated anger, resentment, fear, social isolation and depression. Unfortunately, research support sometimes does not equal patient impact because in the US, the federal research budget fails to equal the public health care cost of the disease 3.

Chronic wound impact

To highlight the impact of CWs on patients' lives and on society as a whole, it is educational to highlight the prevalence and cost (medical and financial) of three common CWs: PUs (the most common of all chronic wounds), VLUs (the most common leg ulcers) and DFUs (the most common foot ulcers).

PUs represent the most common cause of CWs, and between 2 and 3 million PUs are treated in US acute care facilities each year 4, 5. Within the intensive care unit, almost one quarter of patients develop PUs that are often complicated by osteomyelitis, which can potentially lead to septicaemia, with an associated 55% mortality 1. Overall, the presence of PUs increases mortality by 7·23%, and in the US, hospital‐acquired PUs cause over 60 000 deaths annually. PUs are expensive to treat, with an additional average cost of $43 180 per PU‐related hospital stay, leading to a cost of $11 billion annually 1.

VLUs are the most common type of leg ulcer, and recent data suggest that over 2·2 million people are affected in the US 6. While considered the least difficult of chronic wounds to heal, over one third of VLUs remain unhealed, even after 24 weeks of treatment, and many recur 6. Recent US estimates suggest that treating VLUs costs $14·9 billion each year, in large part because of charges for hospitalisations and physician office visits 7.

Nearly 25% of patients with diabetes mellitus (DM) develop a DFU, which translates into a prevalence of 1·5 million Americans suffering from DFUs. Only one third of DFUs heal with standard care 8, 9, and of those that heal, two‐thirds recur. As a result, nearly one of six patients with DFUs eventually requires an amputation. Independent of diabetes control, DFUs also increase the risk for lower extremity amputation, peripheral arterial disease, heart disease and mortality 9. Patients with neuropathic DFUs have a higher 5‐year mortality risk (45–55%) than patients with Hodgkin's disease (18%), breast cancer (18%) and prostate cancer (8%) 10. The reasons for these increased rates of mortality are not clear, although ischaemic cardiopathy is a common cause. DFU treatment is costly, with US annual expenditures estimated to be $13 billion 11.

Throughout the years, various advanced wound therapies have been developed to offer health care providers more options for patient care. In this supplement, we present a number of advanced approaches to managing problematic CWs and AWs. Based on favourable results, some of these treatment strategies have become standard care for some difficult‐to‐treat wounds. Highlighted in the issue is the management of wound bed preparation, negative pressure wound therapy (NPWT), NPWT with instillation, negative pressure therapy (NPT; for temporary abdominal closure), closed incision NPT (ciNPT) and epidermal grafts.

Harries et al. from Cardiff University, Cardiff, UK reviewed recent literature regarding the wound bed preparation concept of TIME (Tissue, Infection/inflammation, Moisture balance and Epithelial edge advancement). TIME is a systematic approach for assessing chronic wounds and allows the health care professional to make therapeutic adjustments based on the application of wound bed management concepts when wound healing stalls. The article summarises up‐to‐date research findings related to wound bed preparation and the TIME approach to CWs.

Shou‐Cheng Teng from Tri‐Service General Hospital, Taipei, Taiwan discusses the use of NPWT using a segmental compartment‐cover technique in the care of five severely burned patients (60–90% total burn surface area). In these patients, NPWT (V.A.C.^® Therapy, KCI; an ACELITY Company, San Antonio, TX) was used to both promote granulation tissue formation following surgical debridement and bolster the skin grafts. All five patients were successfully discharged from care without any complications.

Anghel et al. from MedStar Georgetown University Hospital, Washington, DC reviewed the current evidence for using NPWT with instillation and a dwell time (NPWTi‐d; V.A.C. VERAFLO^™ Therapy, KCI; an ACELITY Company) and the potential role it may play in the reduction of hospital stay, number of debridement operations and cost. A growing body of evidence suggests that NPWTi‐d, along with debridement and systemic antibiotics, is a viable option for adjunctive management of complex wounds with infection, particularly in a compromised host. Although robust, multicentre, prospective, randomised, controlled trials are warranted, NPWTi‐d holds potential and should be considered in select patients.

Luis G. Fernández from Trinity Mother Frances Health System, Tyler, Texas presents an evidence‐based approach in the management of the open abdomen (OA) when closure is not possible. He suggests that the extension of damage control surgery concepts, in conjunction with OA management, for the septic patient requires the general surgeon to have a comprehensive knowledge of this complex subject. The article provides guidance to the acute care and general surgeon on the use of OA‐NPT (ABTHERA™ Open Abdomen Negative Pressure Therapy System, KCI; an ACELITY Company) for OA management, which has become a critical part of the care of these patients.

Christian Willy and colleagues from Bundeswehr Hospital Berlin, Germany; Bundeswehr Hospital, Ulm Germany; and German Heart Center, Berlin, Germany performed literature searches to investigate the use and potential benefits of ciNPT (PREVENA^™ Incision Management System, KCI; an ACELITY Company) on closed, surgical incisions. The article assesses patient risk factors and type of surgery and determines for which type ciNPT may be beneficial.

Janowska et al. from the University of Pisa, Pisa, Italy discuss the use of epidermal micrografts containing melanocytes in patients with stable localised vitiligo. They present a small case study of five patients treated with epidermal micrografts that were harvested using the commercially available epidermal harvesting system (CELLUTOME^™ Epidermal Harvesting System, KCI; an ACELITY Company). The preliminary data obtained in this pilot study are encouraging.

Herskovitz and colleagues from the University of Miami, Florida discuss autologous skin grafting techniques as part of the reconstructive ladder related to skin defect closure techniques. They noted that the disadvantages of providing epidermal coverage with split‐ or full‐thickness skin grafts include not only the need for surgical training, anaesthesia and, often, operating room privileges but also the creation of a wound at the donor site. The use of epidermal skin grafts, which contain only the epidermal layer, can overcome these obstacles because these grafts are harvested without the use of anaesthesia in an office setting and with minimal to no scarring at the donor site. With commercialisation of an epidermal harvesting system (CELLUTOME™), epidermal skin grafts have emerged as an appealing alternative to other autologous grafts for the treatment of chronic and acute wounds.